Comparison of non-radiographic axial spondyloarthritis and ankylosing spondylitis patients in Malaysia

Aim of the workThis study aimed to compare the clinical features, associated comorbidities and treatment patterns of ankylosing spondylitis (AS) patient to those with non-radiographic axial spondyloarthritis (nr-axSpA) in Malaysia.Patients and methodsThis study was conducted in multiple rheumatology centre in Malaysia. Patients with axial spondyloarthritis (axSpA) were included. The AS and nr-axSpA group were compared.ResultsA total of 302 AS patients and 43 nr-axSpA patients were included. The age was comparable (41.7 ± 12.4 vs 38.5 ± 14.3 years; p = 0.13) however the male:female in those with AS was 4.8:1 vs 1.2:1 (p < 0.0001). The diagnostic delay was longer in AS patients (6.04 ± 6.6 vs 3.4 ± 7.3; p = 0.03), more were frequently smoking (50.3 % vs 25.6 %; p = 0.003), were Chinese (56.6 % vs 37.2 %; p = 0.02), had a higher frequency of HLA-B27 (p < 0.0001) and family history of axSpA (p = 0.04).More AS patients experienced inflammatory back pain (p < 0.0001), had higher Bath AS Metrology Index (BASMI) (p < 0.0001) and Bath AS functional index (BASFI) (p = 0.04). Nr-axSpA patients more likely to experience dactylitis (16.3 % vs 5.6 %; p = 0.014) but no significant differences in frequency of enthesitis. The frequency of comorbidities was similar in both groups. The use of non steroidal anti inflammatory drugs was more frequent in AS (p = 0.038) while nr-axSpA patients more likely to receive conventional disease modifying antirheumatic drug (p = 0.002).ConclusionAS and nr-axSpA shared some characteristics but also had some significant difference especially on gender, inflammatory back pain and HLA-B27. This study offers a better understanding of both the subtypes of axSpA in Malaysia.     

The role of Endoplasmic Reticulum Aminopeptidase 1(ERAP1) in Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is an inflammatory arthritis that affects the spine resulting in significant deterioration in quality of life of patients as well as accounts for significant socio-economic burden. The etiology of AS is unresolved but appears to involve both environmental and genetic factors. HLA-B27 is the strongest associated gene in AS. Recent Genome Wide Association Studies (GWAS) have implicated several other genes associated with AS thus affirming the complex, oligogenic nature of the disease. Interestingly the Endoplasmic Reticulum Aminopeptidase 1 (ERAP1) gene has the second strongest association with AS but this association is true only in HLA-B27 positive individuals. As a result there exists a strong possibility that the functional interaction of HLA-B27 and ERAP1 is pathogenic in AS. In this review we preview the biology of HLA-B27 and ERAP1 followed by a discussion of the three main hypotheses of HLA-B27 and ERAP1 interaction in the pathogenesis of AS, namely: the arthritogenic peptide, cell surface homodimer and the unfolded protein response theories of AS pathogenesis. Additionally this review seeks to provide an update on recent advances in the exciting quest to establish the role of HLA-B27 and ERAP1 in the pathogenesis of AS.     

A Turkish version of the Bath Ankylosing Spondylitis Disease Activity Index: reliability and validity

The aim of this study was to develop a Turkish version of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and assess its reliability, validity, and sensitivity to change. The Turkish version was obtained after a translation and back-translation process. Seventy-one patients with ankylosing spondylitis were assessed with it. To assess its validity, patients were also evaluated with the Turkish version of the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Metrology Index (BASMI), the Bath Ankylosing Spondylitis Patient Global Score (BAS-G), and physicians assessments of disease activity. Over 24 h, the Turkish BASDAI did not show significant differences between the two assessments (P>0.05). Correlations were found between BASDAI and all of the evaluation parameters except BASMI (P<0.01). Both BASDAI and BASMI showed significant improvements after 8-week home exercise programmes. The results of this study show that the Turkish version of the BASDAI is reliable, valid, and sensitive to change.     

Defining disease status in ankylosing spondylitis: validation and cross-cultural adaptation of the Arabic Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and the Bath Ankylosing Spondylitis Global score (BASG)

The Bath Ankylosing Spondylitis Functional Index (BASFI), disease activity index (BASDAI), and Global assessment (BASG) are the most commonly used instruments to assess patients suffering from ankylosing spondylitis (AS). The aim of this study was to translate, adapt, and validate these instruments into the Arabic language. Seventy-three AS patients were included in this study. One question in the BASFI questionnaire was changed to suit the Arabic culture. Also, the VAS in the questionnaires was transformed to numerical rating scales from 0 to 10. After modification, translation, and retranslation of the questionnaires, it was administered and tested for internal consistency, reliability, and construct validity. Magnetic resonance imaging (MRI) of the spine and sacroiliac joints was carried out for 69 patients; scores for disease activity and chronicity were also assessed. The adapted and translated questionnaires demonstrated acceptable comprehensibility scores with a mean of 9.3. Intraclass correlation coefficients for reliability and internal consistency was 0.973 for BASG, whereas standardized alpha ranged between 0.807 and 0.976. The modified item 9 in the BASFI demonstrated a good correlate to the principal component (0.883). When validated, all three questionnaires showed a significant correlation with enthesitis, BAS-radiology index, MRI imaging scores for activity and chronicity, C-reactive protein (CRP), and morning stiffness duration. The Arabic version of the BASFI, BASDAI, and BASG, showed adequate reliability and validity in patients with AS. The measurement properties were comparable to versions in other languages indicating that the questionnaires can be used for evaluation of AS Arabic-speaking patients. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Assessment of sexual dysfunction in male patients with Ankylosing Spondylitis

We evaluated sexual dysfunction in male patients with ankylosing spondylitis (AS) using the Brief Male Sexual Function Inventory (BMSFI). We assessed sexual dysfunction using the BMSFI in male patients with AS followed at the outpatient clinic and compared results with those in healthy controls. Depression status was measured by the Beck Depression Inventory in AS patient and control group. The Bath AS functional index was used to measure functional status, the Bath AS metrology index was used to measure joint mobility, and the Bath AS disease activity index was used to evaluate disease activity in AS cases. Compared to healthy controls patients with AS had significantly lower sexual drive, erection, problem assessment and overall satisfaction scores according to the BMSFI. Ejaculation scores were also lower but not statistically significant. According to the Beck Depression Inventory, AS patients had higher scores than healthy controls (14.9 ± 9.4 and 10.3 ± 11.8, P = 0.026, respectively). As for the relation between the BMSFI domains and BDI scores, relation was found only in the domains of problem assessment and overall satisfaction (P < 0.05). The incidence rate of sexual dysfunction is higher in patients with AS, when compared to the healthy people. In patients with AS, sexual dysfunction was associated with depression and limited joint mobility.     

Advances in understanding the pathophysiology of spondyloarthritis

Progressive understanding of the underlying pathophysiology of axial spondyloarthritis has successfully translated into innovative therapeutic strategies and successful management of patients in the clinic. This review summarizes the key roles of the pro-inflammatory cytokines tumor necrosis factor and interleukin-17 in the onset and progression of disease and how these cytokines are instrumental in shaping the concept that enthesitis is a key feature of axial spondyloarthritis. Advances in immunological technologies have led to the important insight that different cell populations, part of both the innate and adaptive immune system, play a key role in axial spondyloarthritis. In addition to inflammation, structural damage to the axial skeleton, in particular progressive ankylosis of the sacroiliac joints and the spine, is key to the outcome of patients. Novel data integrate the role of pro-inflammatory cytokines and enthesitis in this context.     

The concept of spondyloarthritis: Where are we now?

The term spondyloarthritis (SpA) encompasses a group of diseases characterized by inflammation in the spine and in the peripheral joints, and other clinical features such as uveitis, dactylitis, psoriasis, inflammatory bowel disease, and association with human leukocyte antigen (HLA) B27. The spectrum of SpA encompasses axial spondyloarthritis (axSpA) and peripheral spondyloarthritis including psoriatic arthritis (PsA), reactive arthritis (ReA), and inflammatory bowel disease-associated arthritis. In recent years, there has been tremendous progress in understanding the natural history and pathogenetic mechanisms underlying SpA leading to the development of effective treatments. It has become imperative to identify the disease early, and accurately, to avail patients of effective treatments in a safe manner. The development of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria has been a welcome advance in this regard. This article provides a historical evolution of the concept of SpA, from the Rome Criteria to the ASAS criteria, current issues and barriers with the use of ASAS criteria, and the work that still needs to be done moving forward.     

The Turkish version of the Bath Ankylosing Spondylitis Functional Index: reliability and validity

The purpose of this study was to investigate the reliability and validity of the Turkish version of the Bath Ankylosing Spondylitis (AS) Functional Index (BASFI). The Turkish version of the BASFI was obtained after a process of translation and back-translation. Eighty-one consecutive patients meeting the 1984 New York criteria for AS were enrolled. Patients were evaluated and requested to complete the questionnaire at days 1 and 2 and on a third occasion between days 15–90. Reliability, reproducibility, validity and sensitivity to change of the Turkish version of the index were assessed. Each score correlated closely with the index score, with coefficients between 0.727 and 0.844. Reliability analysis showed a Cronbachs alpha score of 0.926. Correlations were found between all items of the BASFI and Schobers test (r=–0.258 to –0.531, p<0.001–0.05), occiput-to-wall distance (r=0.284 and 0.589, p<0.001–0.05), and finger-to-floor distance (r=0.334 to 0.613, p<0.001–0.01). The total index score was correlated with the number of nocturnal awakenings (r=0.515, p<0.001), Schobers test (r=–0.444, p<0.001), finger-to-floor distance (r=0.567, p<0.001), occiput-to-wall distance (r=0.535, p<0.001), chest expansion (r=–0.403, p<0.001), and the Dougados articular index (r=0.371, p<0.01). A good correlation was found between day 0 and 1 BASFI indices (r=0.765–0.917, p<0.001), showing good reproducibility of the index. The Turkish version of the BASFI showed reliability, reproducibility, and validity, confirming its utility in the research of AS in Turkey. However, sensitivity to changes due to drug therapy and/or rehabilitation remains to be determined.     

The Turkish versions of the Bath Ankylosing Spondylitis and Dougados Functional Indices: reliability and validity

Objective The aim of this study was to develop a Turkish version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Dougados Functional Index (DFI) and assess their reliability, validity, and sensitivity to change.Methods The Turkish versions of the BASFI and DFI were obtained after a translation and back-translation process. Seventy-one patients with ankylosing spondylitis (AS) were included in the study. For investigation of the reliability of the BASFI and DFI, 36 of the patients recompleted both indices on the following day. To assess validity, the patients were evaluated with the Bath AS Disease Activity Index (BASDAI), Bath AS Metrology Index (BASMI), Bath AS Patient Global Score (BAS-G), physicians assessment of disease activity, Bath AS Radiology Index-spine (BASRI-s) and sacroiliac joints, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). To assess the sensitivity to change, 16 patients were included in an 8-week home exercise program. In addition, 16 who had been on nonsteroidal anti-inflammatory drug (NSAID) treatment were requested to stop the treatment for 1 to 2 weeks.Results There were no significant differences in BASFI and DFI scores on two occasions within 24 h (P>0.05). The results showed correlations between both of the functional indices and the aforementioned validation parameters except ESR, CRP, and radiologic changes in the sacroiliac joints. The BASFI and DFI scores and BASMI and BASDAI values showed significant improvements in the home-exercise group. For the group of patients whose NSAIDs were stopped, BASFI, DFI, and BASDAI scores showed significant increase, whereas the mean BASMI score did not change.Conclusion The results indicate that the Turkish versions of the BASFI and DFI are reliable, valid, and sensitive to change.     

Comparative analysis between ankylosing spondylitis and axial psoriatic arthritis patients

Aim of the workTo compare clinical aspects, disease activity, spinal mobility, and radiographic findings between ankylosing spondylitis (AS) and axial psoriatic arthritis (axPsA) patientsPatients and methodsFifty-eight AS and 42 axPsA patients were enrolled. Patients were assessed by clinical examination, spinal mobility measurements, and conventional radiographs of the sacroiliac joints, lumbosacral and cervical spines. Bath.AS Metrology Index (BASMI) and modified Stoke AS Spinal Score (mSASSS) were measured. Spondyloarthritis Research Consortium of Canada (SPARCC) enthesitis index score and AS Disease Activity Score (ASDAS) were assessed. Results: The mean age of AS and AxPsA patients were comparable (37.2 ± 11.2 years vs 39.6 ± 13.3 years;p = 0.33) and male:female was 2.63 vs 0.24:1 (p < 0.0001). Inflammatory back pain (IBP) was higher in AS (93.1%) than axPsA (76.2%). Peripheral arthritis was higher in axPsA (85.7%) than in AS (39.7%). Dactylitis and nail dystrophy were present only in axPsA (33.3% and 28.6% respectively) while uveitis was more common in AS (60.3%vs 28.6%;p = 0.12). SPARCC score was higher in axPsA (p = 0.12).The median BASMI was higher in AS (2.1) than axPsA (1.2)(p = 0.07). The mSASSS was similar (AS:19.6 ± 4.7;6–40 and axPsA:14.4 ± 2.1;0–32)(p = 0.23). 63.8% of AS patients had grade 3 sacroiliitis while 61.9% of axPsA had grade 2. 75.9% of AS had high ASDAS while 33.3% of axPsA patients had very high activity (p = 0.039).ConclusionsAS patients were more likely to be males, smoked, higher IBP, lower peripheral arthritis, more uveitis, higher limitation in spinal mobility measurements, more spinal deformities, and severe radiographic involvement with nearly equal disease activity as in axPsA patients.     

Characteristics of Ankylosing Spondylitis patients living in Qatar

Aim of the work

To study the clinical, laboratory and radiographic characteristics of ankylosing spondylitis (AS) patients living in Qatar.

Gender differences in axial spondyloarthritis

Within the concept of axial spondyloarthritis(ax Sp A), relevant differences between men and women have been described for patients with the radiographic disease form [ankylosing spondylitis(AS)]. The subjective perception of disease activity(spinal and peripheral pain, fatigue, morning stiffness) has been shown to be higher in female than in male patients. Moreover, women experience more functional limitations and a lower quality of life, despite lower degrees of radiographic spinal damage. Peripheral clinical involvement(arthritis and enthesitis) is, additionally, more predominant in women. On the other hand, a higher level of objective signs of inflammation(C-reactive protein, erythrocyte sedimentation rate, magnetic resonance imaging of sacroiliac joints and spine) has been reported in men. Whether these differences might explain the better response to treatment with anti-tumor necrosis factor agents observed in male patients remains unclear. The underlying causes of the discrepancies are still unknown and genetic, environmental, cultural and/or societal factors may be involved. While AS is still more prevalent in men in a ratio of 2-3:1, the prevalence of males and females in patients with ax Sp A without radiographic sacroiliac damage is similar. Gender differences in this subgroup of patients have not been adequately addressed, and are particularly needed to further validate the Assessment of Spondylo Arthritis international Society classification criteria.     

Coexistence of Hereditary Multiple Exostoses and Ankylosing Spondylitis

We report a 50-year-old male patient with hereditary multiple exostoses (HME) and ankylosing spondylitis (AS). This is the first case reporting the coexistence of HME and AS. Our patient has multiple exostoses around the knee, elbow and wrist joints. At the age of 40 years, pain in the lower back associated with morning stiffness lasting about an hour and improving with exercise began. His son also has hereditary multiple exostoses but has no sign of AS. HME is an autosomal dominant disorder. AS has a remarkably strong association with the histocompatibility antigen HLA-B27. Owing to the different genetic mechanisms, it is not possible to differentiate between coincidence and association. Coexistence of HME and AS in our patient probably represents a coincidence rather than a real association. Received: 4 September 1998 / Accepted: 4 April 1999     

Ankylosing spondylitis and undifferentiated spondyloarthritis in Kuwait: a comparison between Arabs and South Asians

The objectives of this study were to describe and compare the clinical characteristics of ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (USpA) in Middle East Arab (MEA) and South Asian (SA) patients diagnosed in our unit. Fifty-eight consecutive patients diagnosed with SpA were studied after classifying them into MEA and SA. They were further classified as per disease diagnosis. Excluding three patients with miscellaneous ethnicity, there were 29 MEA and 26 SA patients. Seventy-two percent of MEA patients were males (vs 92% of SA patients). Of the 29 patients with MEA ethnicity, 17 had AS and 9 had USpA. Of the 26 patients with SA ethnicity, 10 had AS and 14 had USpA. Fifty-nine percent of MEA patients had AS (vs 39% of SA patients). Mean age at onset in AS patients was similar in the two ethnic groups. However, in patients with USpA, mean age at onset was somewhat lower at 21.8 years in the MEA group compared with 29.4 years in the SA group. Family history in first-degree relatives was significantly more common in MEA patients. Weight loss, inflammatory spinal pain, gluteal pain, and enthesopathy were equally common in both ethnic groups. Knee, ankle, and metatarsophalangeal joint involvement was less common in MEA patients. There were no significant differences in the occurrence of syndesmophytes, bamboo spine, and sacroiliitis in the two ethnic groups. HLA-B27 positivity rates in MEA patients were 87% for AS and 67% for USpA compared to 75 and 71%, respectively, in SA patients. It is concluded that some significant new findings have arisen from this study: the majority of MEA patients presented with AS, whereas the majority of SA patients had a picture of USpA. Family history was more common in MEA patients. Peripheral arthritis was less common in MEA patients. Worldwide, this is the first study to show that there are significant differences in the clinical expression of the various SpA in MEA patients compared to SA patients.